Pattern of allergic sensitization in chronic rhinitis: A 19-year retrospective study

BACKGROUND

The pattern of allergic sensitization provides data for physicians to take appropriate care of allergic patients.

OBJECTIVE

To analyze the long-term pattern of allergen skin prick test (SPT) sensitization at a single tertiary care hospital in Thailand.

METHODS

Medical records of adult rhinitis patients during 1998 to 2017 were reviewed. Inclusion criteria were chronic rhinitis with positive SPT to at least one aeroallergen in the test panel. Outcome measures were SPT results, clinical symptoms, and their effect on patient quality of life (QoL). Descriptive statistics were used to demonstrate the pattern of sensitization. Multivariate linear regression was used to identify association between evaluated factors and patient QoL.

RESULTS

Six thousand five hundred and seventeen adult patients were included in this study. Mean age was 36.4 & 13.8 years. A majority of patients (59.4%) had positive SPT, and 83.7% of those had polysensitization. Dermatophagoides pteronyssinus and sedge were the most common indoor (54.8%) and outdoor allergens (37.7%), respectively. Compared among the various periods of data collection over a 19-year period, there was no major change in the pattern of sensitization. Considering the most recent data from 2013-2017, the prevalence of sensitization increased from 66.8% to 73.7% (p < 0.001). Clinical symptoms, except sneezing and allergen sensitization, affect QoL of chronic rhinitis patients (p < 0.001).

CONCLUSIONS

House dust mite and sedge are the most common indoor and outdoor allergens. There was no major change in the pattern of sensitization. Almost all allergic symptoms significantly affect QoL.

Association between skin prick test and serum specific immunoglobulin E to American cockroach allergens in allergic rhinitis patients

INTRODUCTION AND OBJECTIVES

American cockroach is a common aeroallergen sensitization in allergic rhinitis (AR) patients. Association between skin prick test (SPT) and specific immunoglobulin E (sIgE) to American cockroach allergen remains uncertain. This study aimed to evaluate the association between SPT and sIgE to American cockroach allergen in patients with AR.

MATERIALS AND METHODS

This cross-sectional study was conducted in Thai AR patients aged 6-25 years from September 2013 to October 2014. SPT and sIgE to American cockroach allergen were performed and the correlation was calculated using SPSS Statistics version 18.

RESULTS

Sixty-seven AR patients, with median age of 15 years were included in this study. SPT and sIgE to American cockroach allergen showed a positive result in 68.7% and 58.2% cases, respectively. Positive SPT or positive sIgE to American cockroach was found in 79.1%. Thirty-two patients (47.8%) tested positive for both SPT and sIgE to American cockroach allergen. Fourteen from a total of 67 cases (20.9%) with negative sIgE had positive SPT to American cockroach, while seven cases (10.4%) with negative SPT had positive sIgE to American cockroach. Moderate correlation was observed between mean wheal diameter (MWD) and sIgE level to American cockroach (r=0.465, p=0.001). No significant correlation was found between MWD of SPT or sIgE level to American cockroach and AR severity.

CONCLUSION

A moderate correlation was observed between MWD of SPT and sIgE level to American cockroach. If SPT is negative in allergic rhinitis patients highly suspected of having American cockroach allergy, serum sIgE should be considered and vice versa.

Prevalence of nasal carriage of Staphylococcus aureus in allergic rhinitis patients and healthy controls in Thailand

BACKGROUND

Staphylococcus aureus has been proposed as a disease modifier of allergic rhinitis (AR) severity. Although several studies have investigated the prevalence of nasal carriage of S. aureus in healthy controls and AR patients, data from Thailand is scarce.

OBJECTIVE

The aim of this study was to determine the prevalence of nasal carriage of S. aureus in AR patients compared with healthy controls in Thailand.

METHODS

This prospective study enrolled non-AR healthy controls and confirmed AR aged 18-60 years who attended the Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during June 2013 and December 2013. To detect nasal carriage of S. aureus, nasal swab was used for specimen collection from the nasal vestibule. S. aureus prevalence was compared between groups. All AR patients were assessed for disease severity and quality of life.

RESULTS

The 200 enrolled participants were evenly divided between the AR and healthy control groups. Nasal swab cultures were positive for S. aureus in 20 of 100 subjects in the healthy control group, and in 21 of 100 subjects in the AR group (p = 0.86). Nasal carriage of S. aureus was significantly more prevalent in males than in females (p = 0.01). None of the investigated factors were found to be significantly associated with AR severity among S. aureus-positive AR subjects.

CONCLUSIONS

The 20% prevalence of S. aureus in AR patients is not different from that of healthy controls in Thailand, and is similar to other reported rates. No significant associations with AR severity were identified.

The prevalence of high risk of obstructive sleep apnea in patients with allergic rhinitis

BACKGROUND

Although allergic rhinitis (AR) has not been acknowledged as a strong risk factor for obstructive sleep apnea (OSA), several pathophysiological linkages between these two conditions have frequently been reported. However, epidemiological data relating to the prevalence of OSA in patients with AR remain scarce.

OBJECTIVE

To investigate the prevalence of patients at high risk for OSA among patients with AR, and to determine the relationship between OSA and severity of AR.

METHODS

Patients aged ≥ 18 years with a diagnosis of AR and positive skin prick test were recruited from the allergy clinic, Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand between October 2014 to November 2015. During routine follow-up, participants were asked to complete the STOP-Bang questionnaire and visual analog scale regarding AR symptoms, including their duration and severity. Patients with STOP-Bang score of ≥ 3 were considered as high risk for having OSA.

RESULTS

Of the 120 AR patients (45 males, 75 females) included, there were 28 patients (19 males, 9 females) who had a STOP-Bang score of ≥ 3 (23.3%), especially for those who had longer duration of AR symptoms (low-risk/high-risk: 60/120 months, p = 0.01). However, no significant relationship was observed between ARIA classification and severity of nasal symptoms of AR for being high risk of OSA.

CONCLUSION

The prevalence of high risk of having OSA in patients with AR was two times higher than that in general Thai population. Early screening and further management for these patients may improve treatment outcomes and quality of life.

Isoforms of Group 1 Allergens from a Tropical/Subtropical Para Grass (Urochloa mutica) Display Different Levels of IgE Reactivity and Cross-reactivity

Summary

Group 1 grass pollen allergens, or beta-expansins, are the most important major allergens from tropical/subtropical grasses. This study aimed to investigate the sequence similarity, and immunoreactivity of group 1 allergens from Para grass (Urochloa mutica). Three isoforms (Uro m 1.01, Uro m 1.02, and Uro m 1.03) were cloned from cDNA of Para grass pollen. The acidic-neutral isoforms rUro m 1.01 and rUro m 1.02 could effectively inhibited beta-expansins in pollen extract of Bermuda and Johnson grasses, suggesting that these isoforms could be major cross-reacting allergens among these grasses. In contrast, the basic isoform rUro m 1.03 had limited IgE reactivity. Thus, group 1 allergens both acidic-neutral and basic isoforms could have markedly different IgE reactivity.

Minimal clinically important difference for the rhinoconjunctivitis quality of life questionnaire in allergic rhinitis in Thai population

Background

Clinical measurement of the severity of allergic rhinitis (AR) can be assessed by symptoms score and patient quality of life (QoL). The magnitude of change in both symptoms and patient QoL should be considered in the management of AR.

Objective

The aim of this study was to determine the minimal clinically important difference (MCID) in AR in Thai population.

Methods

This prospective study recruited AR patients that attended our clinic during September 2011 to February 2012. The Rhinoconjunctivitis Quality of Life (Rcq-36) questionnaire was used to evaluate patient QoL. The Global Rating of Change Scale (GRCS) was used to assess improvement or deterioration in condition. The MCID was determined using an anchor-based method based on the GRCS, which was compared to the MCID determined by a distribution-based method based on the standard deviation (SD).

Results

Three hundred seventy-two patients with chronic rhinitis were recruited. Eighty-four of those had positive skin prick test and be diagnosed as AR. Of those, 79 completed the study and were included in the final analysis. A change of 2 points on the GRCS yielded an MCID for overall QoL of 0.21 ± 0.57. When applying the distribution-based method, an SD of 1.5 SD yielded an MCID for QoL of 0.27. For the rhinitis symptoms domain, the MCID was 0.42 ± 0.72.

Conclusions

The MCID for overall QoL and rhinitis symptoms in Thai AR patients was found to be 0.21 ± 0.57 and 0.42 ± 0.72, respectively. MCID can be applied for determining the clinical significance of treatment efficacy in AR.

Concordance of skin prick test and serum-specific IgE to locally produced component-resolved diagnostics for cockroach allergy

BACKGROUND

Diagnosis of Periplaneta americana (American cockroach, ACR) allergy is commonly performed based on clinical history and skin prick test (SPT) or specific serum IgE (sIgE) measurement. The concordance of the findings with the SPT and sIgE results has never been investigated.

OBJECTIVE

To compare the results of SPT with commercial ACR-extract (C-ACE) and sIgE measurement, using commercial kit and in-house enzyme-linked immunosorbent assay (ELISA) to the locally produced ACR extract (L-ACE) and native Per a 1, Per a 5, Per a 7, and Per a 9.

METHODS

Sera from 66 individuals clinically diagnosed with chronic allergic rhinitis were included; 46 were positive SPT to C-ACE, and 20 were negative. Specific serum IgE levels were established by using a commercial test kit (ImmunoCap) and an in-house IgE-ELISA RESULTS: The percentage the C-ACE SPT-positive cases that were positive by the ImmunoCap-sIgE was 32.6%, indicating low concordance of the 2 assays. With the in-house ELISA, Per a 9 gave the highest sensitivity (98.00%), positive predictive value (PPV; 95.74%), and negative predictive value (NPV; 94.74%) of the sIgE quantification. The correlation coefficients (R) of the L-ACE-SPT and sIgE to L-ACE, Per a 1, Per a 5, Per a 7, and Per a 9 and ImmunoCap sIgE were 0.133, 0.278, 0.419, 0.280, and 0.432, and 0.256, respectively.

CONCLUSION

Skin prick test and sIgE measurement using commercial reagents have low concordance. Data of this study showed that sIgE to the native Per a 9 should be considered as an adjunct to the clinical history in diagnosis of ACR sensitization/allergy, particularly when the SPT and the nasal challenge, which is the gold standard method, cannot be performed.

Glutathione S-transferase (GST) of American Cockroach, Periplaneta americana: Classes, Isoforms, and Allergenicity

Insect glutathione S-transferases (GSTs) play important roles in insecticide/drug resistance and stress response. Medically, GSTs of house dust mites (Dermatophagoides pteronyssinus and Blomia tropicalis) and German cockroach (Blattella germanica) are human allergens. In this study, classes, isoforms and B-cell and allergenic epitopes of GST of American cockroach, Periplaneta americana, the predominant species in the tropics and subtropics were investigated for the first time. Enzymatically active native and recombinant P. americana-GSTs bound to IgE in sera of all P. americana allergic patients that were tested. By gel-based proteomics and multiple sequence alignments, the native GST comprises three isoforms of delta and sigma classes. All isoforms interacted with serum IgE of the cockroach allergic subjects. Molecularly, the protein contains six B-cell epitopes; two epitopes located at β1-α1 and β4-α3 regions bound to patients’ serum IgE, indicating that they are allergenic. P. americana are ubiquitous and their GST can sensitize humans to allergic diseases; thus, the protein should be included in the allergen array for component resolved diagnosis (CRD) of allergic patients, either by skin prick test or specific IgE determination. The GST is suitable also as a target of environmental allergen detection and quantification for intervention of cockroach sensitization and allergic morbidity.

Reliability and validity study of Sino-nasal outcome test 22 (Thai version) in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is one of common health conditions that affects patients' health-related quality of life. Our purpose is to assess the reliability and validity of Thai-version of Sino-Nasal Outcome Test 22 in chronic rhinosinusitis.

METHODS

Permission for translation of SNOT-22 from English language to Thai language was obtained from the developer. The translation process was done based on the international standard of translation method. A total of 80 subjects were recruited into the study and divided into two groups comprising of 50 patients with chronic rhinosinusitis and 30 healthy volunteers. Cronbach's α and Intraclass correlation coefficient were evaluated for its reliability. Validity test was evaluated against VAS score, SF-36 (Thai version) questionnaire and CT scan (based on Lund-Mackay score). Responsiveness was assessed between pre-operative and post-operative scores in 34 patients.

RESULTS

The Thai version of SNOT-22 showed good reliability according to high value of Cronbach's α coefficient (r = 0.929) and intraclass correlation coefficient (r = 0.935). It also showed good validity by its ability to differential the patients with chronic rhinosinusitis from normal (p < 0.001), and different severity of symptoms (p < 0.05). In addition, the SNOT-22 Thai version also showed good responsiveness when compared between pre-operative and post-operative scores (p < 0.001) and also well-performed in effect size calculation (1.37).

CONCLUSION

We demonstrated that Thai -version of SNOT-22 has good reliability and validity, suitable for evaluation of chronic rhinosinusitis symptoms together with severity of the disease and response to treatment.

TRIAL REGISTRATION

Thai clinical trials registry TCTR20170320003. Date of registration 20/03/2017 (retrospectively registered).

Comparison between specific IgE levels and skin prick test results of local and imported American cockroach, dog, cat, dust mites and mold allergen extracts

BACKGROUND

Skin prick test (SPT) and specific IgE (sIgE) are approved for evaluation of allergen sensitization. Local allergen extracts are less expensive and more available but need to be standardized.

OBJECTIVE

To compare SPT results of local and imported allergen extracts and sIgE levels in response to the American cockroach, dog, cat, Dermatophagoides pteronyssinus (Dp), Dermatophagoides farinae (Df) and Cladosporium spp. allergens.

METHOD

This prospective, randomized, double-blind, self-controlled study was performed in respiratory allergic volunteers. Each subject was pricked with local and imported allergen extracts and sIgE levels were measured.

RESULTS

The agreement between SPT results from each local and imported allergen extract was statistically significant, and the level of agreement for dog allergens was very good (kappa > 0.8). All patients with a positive SPT in response to imported Dp allergen extract had positive SPT in response to local Dp allergen extract. Mean wheal diameter of each allergen in both groups showed significant correlation with sIgE levels. The correlation coefficient (CC) for cat allergens showed a very good-to-excellent relationship (CC> 0.75). When compared with sIgE levels, SPT results for imported and local allergen extracts showed comparable sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio (LR)+ and LR-.

CONCLUSIONS

When the SPT results are compared between local and imported allergen extracts, all were found to have significant agreement, with very good agreement for cat allergens. When the SPT results are compared with specific IgE levels, both local and imported allergen extract provided comparable validity.

Comparison of the efficacy and safety of pollen allergen extracts using skin prick testing and serum specific IgE as references

BACKGROUND

Allergen extracts may be different due to the difference in dissemination of allergen-containing species in various geographical areas. Therefore, we wish to develop our own extracts to ensure the precision and quality of diagnosis.

OBJECTIVES

To compare the efficacy and safety of our locally prepared pollen allergen extracts to imported ones, using skin prick testing (SPT) and serum specific IgE (sIgE) as references.

METHODS

This prospective, randomized, double-blinded, self-controlled study was performed in respiratory allergic adult volunteers who are sensitized to at least one kind of pollen. Each subject was pricked with our Bermuda grass, Johnson grass and careless weed pollen allergen extracts, and also with the imported ones. sIgE levels were measured by using ImmunoCAP?.

RESULTS

In 68 volunteers, our Bermuda, Johnson and careless weed extracts showed 91.2%, 45.6% and 54.4% positive SPTs, respectively, while for the imported ones 73.5%, 45.6% and 54.4% SPTs were positive, respectively. No adverse reaction was found in all procedures. The concentration of 10,000 BAU/mL of Bermuda grass, 1 : 20 w/v or 10,000 PNU/mL of Johnson grass and 1 : 40 w/v or 10,000 PNU/mL of careless weed yielded the most positive SPT results. There was no significant difference in mean wheal diameter (MWD) yielded from using local and imported extracts. Significant correlation was found between MWDs of imported pollen extracts and serum sIgE levels (p < 0.01).

CONCLUSIONS

No significant difference between SPT results of local and imported pollen allergen extracts was found. Significant correlation was found between MWDs of imported pollen extract SPT and serum sIgE levels.

Airborne pollen survey in Bangkok, Thailand: A 35-year update

BACKGROUND

Pollen allergy is a growing global health issue. While airborne pollen counts are reported daily in several countries, such information is lacking in Thailand.

OBJECTIVE

This study aimed to survey airborne pollens at five sites in Bangkok, comparing data with the previous study performed 35 years ago in 1980.

METHODS

Sample collection was done using the ROTOROD® sampler by exposing the rods for one hour each day twice a week from May 2012-April 2013.

RESULTS

Overall, we found that the average pollen count was relatively high throughout the year, at an average of 242 grains/m3. The highest peak was found in September (700 grains/m3). Interestingly, we found that the pollen count was noticeably lower in 2012-2013 when compared to the 1980 study. We also observed the approximate shift of pollen peaks about one to two months earlier in the 2012-2013 study. However, the major groups of airborne pollens did not change significantly. Grass, sedge, amaranthus pollens and fern spores still dominated. The unidentified pollen group was the only group with a higher pollen count when compared to the previous study.

Erratum to: Risk and safety requirements for diagnostic and therapeutic procedures in allergology: World Allergy Organization Statement

[This corrects the article DOI: 10.1186/s40413-016-0122-3.].

Risk and safety requirements for diagnostic and therapeutic procedures in allergology: World Allergy Organization Statement

One of the major concerns in the practice of allergy is related to the safety of procedures for the diagnosis and treatment of allergic disease. Management (diagnosis and treatment) of hypersensitivity disorders involves often intentional exposure to potentially allergenic substances (during skin testing), deliberate induction in the office of allergic symptoms to offending compounds (provocation tests) or intentional application of potentially dangerous substances (allergy vaccine) to sensitized patients. These situations may be associated with a significant risk of unwanted, excessive or even dangerous reactions, which in many instances cannot be completely avoided. However, adverse reactions can be minimized or even avoided if a physician is fully aware of potential risk and is prepared to appropriately handle the situation. Information on the risk of diagnostic and therapeutic procedures in allergic diseases has been accumulated in the medical literature for decades; however, except for allergen specific immunotherapy, it has never been presented in a systematic fashion. Up to now no single document addressed the risk of the most commonly used medical procedures in the allergy office nor attempted to present general requirements necessary to assure the safety of these procedures. Following review of available literature a group of allergy experts within the World Allergy Organization (WAO), representing various continents and areas of allergy expertise, presents this report on risk associated with diagnostic and therapeutic procedures in allergology and proposes a consensus on safety requirements for performing procedures in allergy offices. Optimal safety measures including appropriate location, type and required time of supervision, availability of safety equipment, access to specialized emergency services, etc. for various procedures have been recommended. This document should be useful for allergists with already established practices and experience as well as to other specialists taking care of patients with allergies.

Comparison of different local and imported histamine concentrations used as a skin prick test positive control

BACKGROUND

The skin prick test (SPT) is a valid and approved tool that is used to diagnose atopic diseases. The SPT is accurate, safe, simple and inexpensive. However, the histamine concentration used as a positive control in the SPT varies among centers.

OBJECTIVE

To compare SPT results using different concentrations of locally-prepared and imported histamine solutions.

METHOD

This prospective, randomized, double-blind, self-controlled study was performed in healthy adult volunteers. The SPT was performed using 4 concentrations of histamine solutions (imported, 1 mg/mL; locally-prepared, 1, 5 and 10 mg/mL). Locally-prepared histamine positive controls were prepared from histamine biphosphate monohydrate using sterile technique.

RESULTS

Seventy-five adult volunteers (mean age, 36 years) were included in the study. Eight volunteers were male and 9 had a history of atopy. Mean wheal diameter (MWD) for imported histamine was 3.49 mm for a concentration of 1 mg/mL, and that of locally-prepared histamine was 2.94 mm, 5.05 mm and 5.52 mm for concentrations of 1, 5 and 10 mg/mL histamine, respectively. Negative SPT results (MWD <3 mm) were found in 11 subjects (14.7%) who received imported histamine and 26 subjects (34.7%) who received the locally-prepared histamine at concentration of 1 mg/mL. All subjects tested with locally-prepared histamine at concentrations of 5 and 10 mg/mL had a MWD > 3 mm.

CONCLUSIONS

Locally-prepared histamine base at concentrations of 5 and 10 mg/mL yielded better positive results than both imported and locally-prepared histamine at a concentration of 1 mg/mL.

The correlation between intradermal testing and serum specific IgE to house dust mite in negative skin prick test allergic rhinitis adult patients

BACKGROUND

Diagnosis of allergic rhinitis (AR) is based on history, physical examination, and skin prick test (SPT) while intradermal (ID) test can be performed to confirm the diagnosis in case of negative result of SPT. However, the ID test is not recommended for cat and timothy grass allergy because of its high false positive rate. As a result, the "quantitative" technique of serum specific IgE (sIgE) measurement might be helpful to diagnose AR with more confidence.

OBJECTIVES

To evaluate the correlation between ID tests and sIgE in the diagnosis of house dust mite (HDM)-sensitive AR patients.

METHODS

Patients with chronic rhinitis (CR) were recruited and SPT was performed. If SPT was negative, ID test and sIgE to HDM [Dermatophagoides pteronyssinus (Dp)] measurement were performed.

RESULTS

Eighty-two patients with chronic rhinitis (CR), whose SPTs were negative for Dp, were included. There were 39 males (47.6%) and 43 females (52.4%) aged between 18 and 76 years old (mean age = 43.3 years). The ID test was positive in 13 patients (15.9%), and was negative in 69 patients (84.1 %). sIgE to HDM was positive ( ≥ 0.35 kUA/l) in 2 patients (2.4%). There was a fair to moderate correlation between the size of wheal of ID test and sIgE to HDM (r = 0.44, 95% confidence interval: 0.19 to 0.67, p < 0.01).

CONCLUSION

ID test has a fair to moderate correlation with sIgE Dermatophagoides pteronyssinus and it can be used in CR patients with negative SPT where sIgE is not feasible.

A Surveillance Bacteriological Study of Acute Bacterial Rhinosinusitis in Thailand and the Clinical Responses to the Culture-directed Antibiotics

OBJECTIVE

To examine: 1) types of bacteria and antimicrobial sensitivity of commonly used antibiotics for acute bacterial rhinosinusitis (ABRS) in Thailand, 2) the effectiveness of using antibiotics according to antimicrobial sensitivity, and 3) the effectiveness of using antibiotics according to the Thai clinical practice guidelines (CPG) of ABRS.

MATERIAL AND METHOD

Descriptive & experimental studies were conducted in seven tertiary hospitals in Thailand. The specimens from maxillary sinuses were taken for bacterial cultures either by maxillary sinus tap or endoscopically directed middle meatus swabs in patients with clinically diagnosed ABRS. Antimicrobial sensitivity was performed and antibiotics were prescribed according to the results of antimicrobial sensitivity or the Thai CPG of ABRS.

RESULTS

A total of 113 patients were enrolled between August 2006 and April 2007, 104 cases of which were performed for bacteriological study. The incidence of bacterial growth was 60.6% (95% CI 51.0-69.4%). The most common bacteria was H. influenzae (25.0%, 95% CI 16.9-35.3%), followed by S. pneumoniae (14.3%, 95% CI 8.2-23.5%) and S. aureus (9.5%, 95% CI 4.7-17.9%), respectively, whilst M. catarrhalis was found only in 2.4% (95% CI 0.5-7.3%). Eight in 12 S. pneumoniae isolates were tested for the minimal inhibitory concentration of penicillin and found to be penicillin resistant strain in five specimens. Beta-lactamase producing H. influenzae was found in eight out of 20 isolates. H. influenzae had a tendency to be sensitive to amoxicillin/clavulanate, cefuroxime, cefpodoxime, azithromycin, clarithromycin, ofloxacin, levofloxacin and gatifloxacin, whilst S. pneumoniae had a tendency to be sensitive to amoxicillin/clavulanate, cefaclor ampicillin/sulbactam, cefuroxime, ofloxacin, levofloxacin, gatifloxacin, cefpodoxime, cefixime and cefdinir. The effectiveness of antibiotics prescription according to the Thai CPG of ABRS and antimicrobial sensitivity were comparable, 88.5% (95% CI 69.8-97.6%) and 82.2% (95% CI 67.9-92%), respectively.

CONCLUSION

H. influenzae is found to be the most common bacteria in Thai ABRS, followed by S. pneumoniae and S. aureus. There is a high incidence of beta-lactamase producing H. influenzae and penicillin non-susceptible S. pneumoniae.

ICON: chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a public health problem that has a significant socio-economic impact. Moreover, the complexity of this disease due to its heterogeneous nature based on the underlying pathophysiology - leading to different disease variants - further complicates our understanding and directions for the most appropriate targeted treatment strategies. Several International/national guidelines/position papers and/or consensus documents are available that present the current knowledge and treatment strategies for CRS. Yet there are many challenges to the management of CRS especially in the case of the more severe and refractory forms of disease. Therefore, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), a collaboration between EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus (ICON) on Chronic Rhinosinusitis. The purpose of this ICON on CRS is to highlight the key common messages from the existing guidelines, the differences in recommendations as well as the gaps in our current knowledge of CRS, thus providing a concise reference. In this document we discuss the definition of the disease, its relevance, pharmacoeconomics, pathophysiology, phenotypes and endotypes, genetics and risk factors, natural history and co-morbidities as well as clinical manifestations and treatment options in both adults and children comprising pharmacotherapy, surgical interventions and more recent biological approaches. Finally, we have also highlighted the unmet needs that wait to be addressed through future research.

Radiofrequency inferior turbinate reduction improves smell ability of patients with chronic rhinitis and inferior turbinate hypertrophy

Radiofrequency inferior turbinate reduction (RFITR) of inferior turbinate hypertrophy (ITH) is an effective way to treat patients with intractable nasal mucosal obstruction. The objective of this study was to assess smell ability, nasal symptoms, inferior turbinate grading (ITG), peak nasal inspiratory flow (PNIF) of patients with chronic rhinitis (CR), and ITH before and after RFITR. Patients with CR and ITH, aged 18–60 years, who underwent RFITR, were prospectively recruited. Smell ability (measured by smell detection threshold [SDT]), visual analog scale (VAS) of nasal symptoms, ITG, and PNIF before and 6–10 weeks after RFITR were compared. Forty-eight subjects were included. All nasal symptoms were significantly decreased after RFITR. After surgery, SDT (tested by phenyl ethyl alcohol) was worsened in 7 patients (14.6%), improved in 8 patients (16.7%), and did not change in 33 patients (68.7%). SDT after RFITR of six patients in the worsened SDT group were still within normal range (> −6.5). There was only one patient whose SDT changed from normosmia to mild hyposmia (−7.25 to −5.38). In the improved SDT group, two of eight patients had obviously better SDT after RFITR, which changed from moderate hyposmia to normosmia (−3.65 to −10; −3.73 to −10), whereas six of eight patients had little better SDT after RFITR. RFITR also significantly reduced ITG and improved PNIF. In conclusion, the treatment of patients with CR and ITH with RFITR significantly improved PNIF, ITG, and nasal symptoms assessed by VAS, although SDT after RFITR could be the same or improved or worsened.

Prevalence of chronic rhinitis in Thai patients with obstructive sleep disordered breathing

OBJECTIVE

To prospectively identify the prevalence of chronic rhinitis (CR) and findings from objective nasal airway evaluation in Thai patients with obstructive sleep disordered breathing (OSDB) in a sleep clinic.

MATERIAL AND METHOD

Seventy patients, 44 males and 26females, with OSDB were recruited. All were asked to complete Epworth sleepiness scale (ESS), questionnaires regarding nasal symptoms including scores to assess the severity of CR, and objective nasal airway measurements. Nasal airway resistance (NAR) was measured by active anterior rhinomanometry and nasal volume and minimal cross-sectional area (MCA) were measured by acoustic rhinometry (before topical decongestion).

RESULTS

Fifty-nine patients (84.3%) had a history of nasal obstruction, rhinorrhea, sneezing, and itching of either intermittent or persistent pattern, regardless of severity, for more than one month. Forty-six patients (65.7%) had active symptom of nasal obstruction. About 23% of patients had NAR higher than and 33% had MCA lower than 1 SD from the mean of normative values in healthy Asians. Both subjective and objective nasal parameters did not have a statistically significant correlation with the scores of ESS.

CONCLUSION

A substantial proportion of patients with OSDB in the sleep clinic had co-existing CR symptoms and a tendency to be abnormal in objective nasal parameters when compared to general population. Careful history recording and a thorough evaluation of the nasal airway are, therefore, essential in these patients.

Inflammatory patterns in upper airway disease in the same geographical area may change over time

BACKGROUND

Inflammatory patterns of nasal polyps (NPs) may vary. Changes over time have not been investigated so far. This study was designed to evaluate the inflammatory patterns of NPs in Thailand at two time points 12 years apart, explore differences in Staphylococcus aureus (SA) mucosal carriage rates over time, and the latter's relationship with the inflammatory patterns.

METHODS

Formalin-fixed nasal tissue was obtained from 89 (47 in 1999 and 42 in 2011) patients suffering from chronic rhinosinusitis with NPs (CRSwNPs). Tissues were evaluated for eosinophils, neutrophils, IgE(+) cells, IgE and macrophage mannose receptors, interleukin (IL)-5 and IL-17 cytokine profile, and the presence of SA, using automated immunohistochemistry and peptide nucleic acid-fluorescence in situ hybridization.

RESULTS

We found a significant increase in the absolute values of eosinophils and IgE(+) cells in the 2011 CRSwNP tissue series compared with 1999 and a significant but smaller increase in neutrophils. Semiquantitative evaluation revealed significantly higher mean values of positive cells for all studied inflammatory markers in the 2011 group of patients, except for the high-affinity IgE receptor. This "eosinophilic shift" of inflammation was accompanied by higher SA carriage, as well as higher frequencies of SA invasion (54.8% versus 10.6%; p < 0.001) in the 2011 compared with 1999 subjects. Patients with asthma were more likely to have higher SA carriage rates compared with nonasthmatic patients.

CONCLUSION

There was a shift from predominantly neutrophilic to eosinophilic CRSwNPs in Thai patients within 12 years, with an increase in various inflammatory markers including IgE, which is associated with an increase in intramucosal presence of SA.

Patient preference and sensory perception of three intranasal corticosteroids for allergic rhinitis

OBJECTIVE

To evaluate the medication preference, sensory perceptions and compliance of allergic rhinitis patients after a single administration of three intranasal corticosteroids.

STUDY DESIGN AND SUBJECTS

In this double-blind, comparative, crossover study, 364 patients were randomised to receive fluticasone propionate (FP), mometasone furoate (MF) and triamcinolone acetonide (TAA) nasal sprays. Patients completed a preference questionnaire including a product preference and compliance evaluation after administration to determine the acceptability of each product.

RESULTS

The results indicate that TAA was judged more comfortable (p = 0.0406), had less odour (p < 0.0001) and had a significantly greater overall liking (p = 0.0008) compared with FP and MF. The nasal spray 'most preferred to be prescribed' was TAA (38.2%), followed by FP (36.8%) and MF (24.9%). Furthermore, 82.3% of the patients indicated that they would 'definitely comply' with a doctor's prescription for TAA, compared with 39.6% for FP and 20.5% for MF.

CONCLUSION

The results of this study indicate that TAA is the most favourable nasal spray in terms of preference and sensory perceptions for patients with perennial or seasonal allergic rhinitis.

Comparison of allergenic components and biopotency in whole body extracts of wild and laboratory reared American cockroaches, Periplaneta americana

BACKGROUND AND OBJECTIVE

Most allergen extracts/vaccines used today in clinical practice are derived from natural allergen sources. Therefore, their allergic components may vary as these are prone to natural variation. This study aims to compare the allergenic components and biological potency of crude extracts from wild and laboratory reared American cockroaches.

METHODS

Crude extracts of male and female of wild and laboratory reared American CR, were prepared by the same method. Their allergenic components were evaluated by in vitro assays such as protein contents, protein profiles, quantification of major allergens (Per a 1 and Per a 9) and IgE inhibition ELISA assay.

RESULTS AND DISCUSSION

There was no statistically significant difference between the protein contents and the concentrations of Per a 1 in the crude extracts from both groups. However, the Per a 9 levels in extracts of wild CR were significantly higher than those from the extracts of laboratory reared CR. The protein patterns of the extracts of laboratory reared CR exhibited more consistency in the number of bands with higher intensity than those of wild CR. Pooled extracts of laboratory reared CR could inhibit IgE binding to that of wild CR up to 78%. The endotoxin content of extracts of laboratory reared CR were ten times less than those of the the wild CR. We have successfully determined the allergenic potency of the extracts of laboratory reared CR versus those of the wild CRs by in vitro assays. Further studies should be performed to determine the biological potency of CR extracts by in vivo assays for clinical application.

CONCLUSION

Our finding indicates that the laboratory reared CR would be the better source of material in vaccine production than the wild CR.

Staphylococcus aureus superantigens and their role in eosinophilic nasal polyp disease

Nasal polyposis is a chronic disease of the upper airways which adversely affects the quality of life of patients. Its pathophysiology is still unclear. Recently, several studies have shown different inflammatory pathways which relate to both innate and adaptive immune responses. Moreover, different phenotypes may exist in different ethnic groups of patients. This article will review recent data regarding the type of inflammation, cytokine profiles, involvement of macrophages and dendritic cells, and the impact of various organisms (especially Staphylococcus aureus and its superantigens) and their association with lower airway disease (especially asthma).

Nuts and seed: a natural yet dangerous foreign body

RATIONALE AND AIM

This paper has the object to present the impact of nuts' and seeds' injuries withdrawing data from the Susy Safe registry, highlighting that as for other foreign bodies the main item efficiently and substantially susceptible to changes to decrease the accidents' rates is the education of adults and children, that can be shared with parents both from pediatricians and general practitioners. Indeed labeling and age related warnings have also a fundamental relevance in prevention.

METHODS

The present study draws its data from the Susy Safe registry. Details on injuries are entered in the Susy Safe Web-registry through a standardized case report form, that includes information regarding: children age and gender, features of the object, circumstances of injury (presence of parents and activity) and hospitalization's details (lasting, complications and removal details). Cases are prospectively collected using the Susy Safe system from 06/2005; moreover, also information regarding past consecutive cases available in each centre adhering to the project have been entered in the Susy Safe registry.

RESULTS

Nuts and seeds are one of the most common food item retrieved in foreign bodies injuries in children. In Susy Safe registry they represent the 38% in food group, and almost the 10% in general cases. Trachea, bronchi and lungs were the main location of FB's retrieval, showing an incidence of 68%. Hospitalization occurred in 83% of cases, showing the major frequency for foreign bodies located in trachea. This location was also the principal site of complications, with a frequency of 68%. There were no significant associations between these outcomes and the age class of the children. The most common complications seen (22.4%) was bronchitis, followed by pneumonia (19.7%). Adult presence was recorded as positive in 71.2% of cases, showing an association (p value 0.009) between the adult supervision and the hospitalization outcome. On the contrary there was a non significant association between adult presence and the occurrence of complications. In 80.7% of cases, the incident happened while the child was eating. Among those cases, 88.6% interested trachea, lungs and bronchi.

CONCLUSIONS

Food-related aspiration injuries are common events for young children, particularly under 4 years of age, and may lead to severe complication. There is a need to study in more depth specific characteristics of foreign bodies associated with increased hazard, such as size, shape, hardness or firmness, lubricity, pliability and elasticity, in order to better identify risky foods, and more precisely described the pathogenetic pathway. Parents are not adequately conscious and aware toward this risk; therefore, the number and severity of the injuries could be reduced by educating parents and children. Information about food safety should be included in all visits to pediatricians in order to make parents able to understand, select, and identify key characteristics of hazardous foods and better control the hazard level of various foods. Finally, preventive measures including warning labels on high-risk foods could be implemented.

A randomized, prospective, double-blind study of the efficacy of dexpanthenol nasal spray on the postoperative treatment of patients with chronic rhinosinusitis after endoscopic sinus surgery

OBJECTIVE

To assess the efficacy of dexpanthenol nasal spray compared with normal saline spray in the postoperative treatment of patients with chronic rhinosinusitis (CRS) who underwent endoscopic sinus surgery (ESS).

MATERIALS AND METHOD

A prospective, randomized controlled study was conducted in CRS patients who underwent ESS. The enrolled patients had never been operated intranasally. These patients received either dexpanthenol or normal saline nasal spray intranasally four times a day for six weeks post-operatively.

RESULTS

Fifty CRS patients were recruited in the present study. Age ranged from 23 to 63 years (means 43.4 +/- 11.2 years). Forty-four percent of patients were diagnosed as CRS without nasal polyps (NP) (CRSs NP) and 56% were CRS with NP (CRSw NP). Twenty-five cases were randomly assigned to use dexpanthenol nasal spray whereas the other 25 cases used normal saline nasal spray. The preoperative severity of CRS, determined by the computerized tomography (CT) scan scoring system of Lund-McKay was 13.9 +/- 6.2 in the dexpanthenol group and 13.6 +/- 6.9 in the normal saline group, which were not statistically different (p > 0.05). The endoscopic scoring was 10.2 +/- 2 in the dexpanthenol group and 10.7 +/- 3 in the normal saline group, which were not statistically different (p > 0.05). The mucociliary transit time improvement (time difference between pre- and post-treatment by nasal spray) was 8.4 +/- 3.3 minutes in the dexpanthenol group and 1.7 +/- 1.2 minutes in the normal saline group, which were statistically different (p < 0.05).

CONCLUSION

The majority of the postoperative symptom scores and all of the endoscopic scores of the dexpanthenol group were not statistically different from those of the normal saline group. However, dexpanthenol nasal spray has superior efficacy compared with normal saline nasal spray on improvement of mucociliary clearance and nasal discharge in the postoperative care of CRS patients after ESS.

Quantification of Der f 1 in houses of patients allergic to house dust mite, Dermatophagoides farinae, using a locally produced detection reagents

BACKGROUND

House dust mite (HDM) allergen quantification in house dust samples before and after the allergen elimination is one means of convincing the target population about the health benefits of allergen removal from their environment.

OBJECTIVE

To produce local reagents for quantification of Der f 1 (major allergen of Dermatophagoides farinae) in dust samples from houses of HDM allergic Thai patients.

METHODS

Recombinant Der f 1 was used for immunization of a BALB/c mouse for hybridoma production. Polyclonal antibody (PAb) to whole body extract of D. farinae was prepared from an immunized rabbit. A sandwich ELISA (MAb-allergen-PAb) was used, in comparison with the commercialized reagents (Indoor Biotechnology, UK), to quantify Der f 1 in dust samples.

RESULTS

Two hybridoma clones, Dfl-1 and Dfl-2, were established. Their secreted MAbs (MAbDfl-1 and MAbDfl-2, respectively) bound to the homologous antigen as well as native Der f 1 and a crude extract of D. farinae. Epitopes of MAbDfI-1 and MAbDfl-2 were located at amino acid residues 206NSQHYGISNYCQ217 and 283DYW---NSWD-WGDSG298 of Der f 1. MAbDf-1 had higher affinity to Der f 1 than the MAbDfl-2. A sandwich ELISA (MAbDfl-1-allergen-PAb) and commercialized reagents (MAbl-allergen-MAb2 sandwich ELISA) were used in comparison for quantification of Der f 1 in 42 dust samples collected from bedrooms and living rooms of 21 houses of the HDM allergic patients. All of the 42 dust samples measured by both ELISAs had the Der f 1 levels higher than 2 mg per gram of fine dust which is the HDM allergy sensitizing level. In addition, Der f 1 levels in 41 samples (except 1 sample from a living room) measured by the MAbDfI-1-PAb and MAbl-MAb2 sandwich ELISAs were higher than 10 mg per g of dust which is the morbidity level of HDM allergen. The local sandwich ELISA showed a high coefficient correlation (r = 0.91) in measuring known amounts of recombinant and native Der f 1. The results indicate that the reagents produced in the present study can be used for measuring the environmental levels of HDM Der f 1. The assay can also be used for standardization of the HDM extract for monitoring patient's allergenic status or for immunotherapeutic purpose.

In-vivo allergenic potency of Siriraj Mite Allergen Vaccine (SMAV) comparing with standardized vaccine in mite-sensitive patients

BACKGROUND

The prevalence of allergic diseases, particularly asthma and allergic rhinitis, has increased tremendously in Thailand and worldwide. House dust mite (HDM) is the major IgE sensitizer among allergic children and adults. We have developed local standardized mite allergen extracts, Siriraj Mite Allergen Vaccine (SMAV) from Dermatophagoides pteronyssinus (Dp) and Dermatophagoides farinae (Df) from our source materials which were highly purified (99%).

OBJECTIVE

To compare in-vivo allergenic potency of both SMAV Dp and Df with commercial standardized mite allergen vaccine by using skin prick testing in mite-sensitive individuals.

METHODS

This was a double-blind, randomized, self controlled study comparing SMAV and commercial standardized mite allergen vaccine (Dp and Df) by using skin prick testing in mite-sensitive adult volunteers, 18-60 years of age.

RESULTS

The study was performed in 54 adult volunteers (19 males, mean age 26.6 +/- 5.5 years old) who had positive skin test to commercial Dp and Df. Seventeen of them had no allergic disease. The most common allergic disease among the volunteers was allergic rhinitis (21/37). Mean wheal diameter of SMAV Dp and commercial Dp at the concentration of 10,000 and 5,000 AU/ml were equivalent but at the concentration of 2,500 AU/ml was inequivalent. Mean wheal diameter of SMAV Dp was significantly larger than commercial Dp at concentration of 2,500 AU/ml (p < 0.05). Mean wheal diameter of SMAV Df and commercial Df at all .3 concentrations were equivalent. There was no systemic side effect in all subjects.

CONCLUSION

The study demonstrated that in mite-sensitive adults, SPT using SMAV Dp (10,000 AU) and Df (10,000 AU) had equivalent allergenic potency to the commercial comparator without any systemic side effect.

Quality of life in patients with chronic rhinitis after radiofrequency inferior turbinate reduction

OBJECTIVE

This prospective, before-and-after study was aimed to demonstrate the effectiveness of radiofrequency (RF) inferior turbinate reduction in patients with chronic rhinitis refractory to medication on quality of life.

MATERIAL AND METHOD

From April 2007 to April 2008, there were 28 patients enrolled in the present study. The temperature-controlled radiofrequency (RF) was applied at inferior turbinate on both sides. To compare before and at the 8th weeks after RF treatment, the patients were given Rhinoconjuctivitis Quality of Life questionnaires (Rcq-36) and questionnaires using visual analog scales (0-10) to assess subjective symptoms such as the frequency and severity of nasal obstruction, nasal discharge, hyposmia, and sneezing. The acoustic rhinometry and active rhinomanometry were also done to evaluate objective outcomes.

RESULTS

At the 8th week after RF treatment, the patients quality of life in every dimension of Rcq-36 and all symptoms revealed a significant improvement (p < 0.05). Particularly, the severity and frequency of nasal congestion were reduced from 6.8 +/- 2.5 and 6.3 +/- 2.5 to 2.6 +/- 2.2 and 2.5 +/- 2.1 respectively (p < 0.001). However, there was no statistically significant change in objective findings. All patients reported only minimal pain and no complication.

CONCLUSION

This is the first study to show that radiofrequency inferior turbinate reduction can improve quality ofhlife ofthe patients with chronic rhinitis in all dimensions. It is a simple and minimal invasive procedure, and thus will be a good alternative treatment.

Comparison between Siriraj mite allergen vaccine and standardized commercial mite vaccine by skin prick testing in normal Thai adults

House dust mite is a major cause of allergic asthma and rhinitis in Thai population. Skin prick test (SPT) is a useful tool for the diagnosis of the IgE-mediated reactions. The imported commercial mite vaccine for SPT is available but it is relatively expensive. Aim of this study is to compare Siriraj Mite Allergen Vaccine (SMAV) with standardized commercial mite allergen vaccine by skin prick testing in normal Thai adults. A double blind, self-controlled study between the SMAV and standardized commercial mite allergen vaccine was performed by SPT in 17 normal Thai adult males and non-pregnant or non-lactating females aged 18-60 years. The study showed that 35.29 % of non atopic adults had positive SPT reaction to Dp and Df of both SMAV and standardized commercial mite allergen vaccine. Mean wheal and flare diameters from SPT of Dp and Df of SMAV showed strong correlation with standardized commercial mite allergen vaccine (r= 0.768 and 0.897 in Dp and Df respectively, p <0.001). The intraclass correlation was also excellent (0.893 and 0.775 in Dp and Df respectively). There was no significant difference in wheal and flare diameter between SMAV and standardized commercial mite allergen vaccine. No systemic or large local reaction was found in any of the study cases.

Allergic rhinitis and its impact on asthma update (ARIA 2008)--western and Asian-Pacific perspective

The prevalence of allergic diseases such as allergic rhinitis (AR) and asthma is markedly increasing worldwide as societies adopt western life styles. Allergic sensitization is an important risk factor for asthma and AR, and asthma often co-exists with AR. An estimated 300 million people worldwide have asthma, about 50% of whom live in developing countries and about 400 million people suffer from AR. Yet, AR is often under-diagnosed and under-treated due to a lack of appreciation of the disease burden and its impact on quality of life, as well as its social impact at school and at the workplace. However, AR with or without asthma is a huge economic burden. Thus, there was clearly a need for a global evidence-based document which would highlight the interactions between the upper and lower airways including diagnosis, epidemiology, common risk factors, management and prevention. The Allergic Rhinitis and its Impact on Asthma (ARIA) document was first published in 2001 as a state-of-the-art guideline for the specialist, the general practitioner and other health care professionals. Subsequent new evidence regarding the pathomechanisms, new drugs and increased knowledge have resulted in the publication of the ARIA 2008 update. The present review summarizes the ARIA update with particular emphasis on the current status of AR and asthma in the Asia-Pacific region and discusses the Western and Asian perspective.

Smell disorders: a study of 132 patients from the first Smell and Taste Clinic of Thailand

OBJECTIVE

To investigate types and possible causes of smell disorders in patients who attended the Smell and Taste Clinic, Siriraj Hospital.

MATERIAL AND METHOD

Medical records of patients with smell disorders who attended the Smell and Taste Clinic, Siriraj Hospital between July 2002 and August 2005 were reviewed for gender age, duration of complaint, severity (hyposmia or anosmia), and previous medical illnesses (e.g., upper respiratory tract infection (URI), head injury, sinonasal problems, etc). All patients had complete physical examination, nasal endoscopy, and phenyl ethyl alcohol (PEA) olfactory threshold test.

RESULTS

One hundred and eighty eight patients' medical records were reviewed. Smell disorders were confirmed in 132 cases (male=58, female=74). Nearly an equal number of anosmia and hyposmia cases were found (50.8% and 49.2% respectively). Possible causes of smell disorders were categorized as follows: sinonasal disease (SND) (66.7%), head injury (12.1%), idiopathic cause (10.6%), URI (6.8%), congenital cause (3%), and others (0.8%). SND was the most common cause of smell disorders despite different age groups and duration of smell disorders. PEA test scores were higher in head injury and idiopathic groups compared with those in SND and post URI groups.

CONCLUSION

The present data showed that SND was the major cause of smell disorders in every age group and in each duration group followed by head injury, idiopathic cause, and URI respectively. Therefore, nasal endoscopy is highly recommended for every patient with smell disorders.

Smell detection threshold in Thai adults

The objective of this study was to prospectively find the normal values of smell detection threshold (SDT) in Thai adults using glass sniff bottle technique. The authors studied 131 healthy Thai adults (65 male and 66 female, aged 20 to 60 years, median 26 years). In this test, different concentrations of phenyl ethyl alcohol (PEA) were applied according to a pre-established order The SDT values were estimated using a 7-reversal initially ascending single staircase procedure and presented as log values of lowest concentration of PEA that could be detected. The results of the present study showed that the median value of SDT in Thais was -12.3 and both male and female were equally -12.3. The value from the present study can be used as a standard reference for patients who have olfaction problems both in routine clinical practice and in research study.

Acoustic rhinometry of Asian noses

BACKGROUND

Each ethnic group has different nasal cavity geometries. The reference value of the minimal cross-sectional area (MCA) and the nasal volume (NV) is mandatory for rhinologic evaluation in regular practice and for research. This study was designed to study the normal value of acoustic rhinometry (AR) in Asian subjects in comparison with other ethnic groups.

METHODS

AR was performed in 135 healthy Thai subjects. Subjects were divided into two groups: group I, with normal anterior rhinoscopic appearance; group II included subjects with asymptomatic, slightly deviated nasal septa.

RESULTS

The mean of the MCA was 0.61 +/- 0.60 cm2 before decongestion and 0.64 +/- 0.14 cm2 after decongestion. The mean distance from the nostril to the point of MCA (D) was 1.66 +/- 0.59 cm before decongestion and 1.41 +/- 0.74 cm after decongestion. The mean of the NV measured between 0 and 4 cm was 3.66 +/- 0.67 cm3 before decongestion and 4.18 +/- 0.75 cm3 after decongestion. Before decongestion, there were no significant differences in the mean of the MCA, D, and NV between group I and group II subjects; however, there were significant differences in mean MCA and NV after decongestion. There were no differences in the parameters between male and female subjects before decongestion, except for the D, but after decongestion the mean values of the MCA, D, and NV were significantly higher in male subjects compared with female subjects.

CONCLUSION

The results of this study can be used as a reference value for Asian ethnicities. Thai subjects had measurements comparable with those of the European study and somewhat different from the study in black populations.

Epidemiology and current status of allergic rhinitis and asthma in Thailand -- ARIA Asia-Pacific Workshop report

The allergic diseases of the airway, i.e. allergic rhinitis and asthma, are on the increase in Thailand and their prevalence shows no signs of abating. When compared with a previous study, the incidence of wheezing had increased 4 fold (from 4.2% to 18.3%), and allergic rhinitis increased nearly 3 fold (from 17.9% to 44.2%). The results of the ISAAC phase III study revealed that the frequency of allergic diseases of the respiratory tract increased significantly from the ISAAC phase I survey performed in 1995; i.e. asthma increased from 12.2% to 14.5%, and allergic rhinitis from 37.9% to 50.6%. Allergic rhinitis exerts a major impact on the quality of life of Thai patients. The results of skin prick testing have indicated the leading causes of indoor (house-dust mites, house dust, cockroaches, dogs and cats) and outdoor pollen (Bermuda grass, para grass, sedge, careless weed) allergens. Molds (represented by Cladosporium), although prominent in an aeroallergen survey, returned a low percentage of positive skin prick reactions, and therefore, were considered low in allergenicity. In Thailand, there are clinical practice guidelines for both allergic rhinitis and asthma which are comparable to the international guidelines like ARIA and GINA. Sufficient kinds of pharmacotherapy are on the National List of Essential Drugs. Yet due to the limited number of trained allergists, many patients are seen by general physicians, and often, the appropriate diagnostic tests and treatments are not provided. In addition, the financial burden for quality health care may be prohibitive for those without private health insurance in spite of the implementation of a universal health care system for all Thai citizens, which is less than optimal.

Allergenicity of native/recombinant tropomyosin, per a 7, of American cockroach (CR), Periplaneta americana, among CR allergic Thais

In this study, native tropomyosin (Per a 7) of American cockroach (CR), Periplaneta americana, caught in Thailand was purified. Also, gene sequence encoding full length tropomyosin of the CR was PCR amplified by using degenerate primers designed from gene sequences coding for P. americana tropomyosin of the database (Per a 7.0101 and Per a 7.0102; accession no.Y14854 and AF106961, respectively). Amino acid sequence deduced from the nucleotide sequence encoding P. americana tropomyosin of this study (GenBank accession no. FJ976895) had 98.59% identity with the sequences of Per a 7.0101 and Per a 7.0102 and was 97.18% identical to the Bla g 7 sequence of German cockroach, Blatella germanica (accession no. AF260897). The native and recombinant tropomyosins (approximately 34 kDa) were used as antigens in sandwich ELISA for detecting specific IgE in serum samples of 14 consented allergic patients who were positive by skin test to crude CR extract in comparison to 5 individuals who were skin test negative. It was found that 8 (57%) and 6 (43%) of the CR allergic patients gave positive IgE binding results to the native and the recombinant proteins, respectively, while none of the non-allergic counterparts was positive. Results of immunoblotting conformed to the ELISA results. Tropomyosin extracted from the P. americana caught in Thailand has potential as standard P. americana allergen in clinical monitoring of the allergic Thai patients.

Efficacy of spiramycin as an alternative to amoxicillin in the treatment of acute upper respiratory tract infections

This study compared the efficacy of spiramycin with that of amoxicillin in treating patients with acute community-acquired upper respiratory tract infections (URTIs). The study was an open, randomised, comparative parallel design and patients received either spiramycin 3 MIU (2 tablets, 500mg or 1.5 MIU per tablet) twice daily after meals, i.e. 6 MIU/day for 7 days or amoxicillin (500 mg/capsule) 1 capsule three times daily after meals, i.e. 1500 mg/day for 7 days. Patients attending the ENT outpatient clinic at Siriraj Hospital in Bangkok for treatment of acute URTIs were included in the study after giving their informed consent. Eligible patients comprised those aged 18 years and over, of either gender, who had at least two of the following symptoms: fever (>/=38 degrees C oral), nasal discharge/obstruction, sore throat, cough and/or hoarseness of voice that did not require parenteral drug therapy or hospitalisation. A total of 99 patients were included in this study, 49 patients received spiramycin and 50 received amoxicillin. Of the 45 assessed patients treated with spiramycin, 40 were judged by the investigators as a 'success' (89%), and five were judged a 'non-success' (11%), compared with 48 assessed patients in the amoxicillin group where 40 patients were classified as a 'success' (83.3%) and 8 were judged a 'non-success' (16.7%). No statistically significant differences between treatments were demonstrated regarding the overall efficacy of treatment. This study demonstrated that the prescribed regimens of spiramycin and amoxicillin were similarly effective in the treatment of adult acute URTIs. The tolerability of both drugs was also similar. Furthermore, it was noted that the convenient twice-daily dosage regimen of spiramycin may allow better patient compliance.

Native troponin-T of the American cockroach (CR), Periplaneta americana, binds to IgE in sera of CR allergic Thais

The American cockroach, Periplaneta americana, is the predominant cockroach (CR) species in Thailand and a major source of indoor allergens second only to the house dust mite. The incidence of CR allergy among allergic Thai patients is increasing but basic information on the allergenic components is scarce. In this study a recombinant troponin-T was produced by using cDNA prepared from RNA of the P. americana as a template and PCR primers designed from the P. americana troponin-T sequence deposited in the GenBank database. The recombinant protein (Mr approximately 50) did not bind to IgE in the sera of 18 skin prick test positive CR allergic patients. Rabbit polyclonal antiserum (PAb) against the recombinant troponin-T was produced and used in preparing an affinity column for the purification of native troponin-T from the crude P. americana extract (Mr approximately 47). IgE-immunoblotting revealed that the native protein bound to IgE in 3 of the 18 (16.7%) patients. Our results imply that native P. americana troponin-T, but not its recombinant counterpart, is a minor allergen among the CR allergic Thais.

A comparative study of patients' preferences and sensory perceptions of three forms of inhalers among Thai asthma and COPD patients

In 9 study centers, 419 patients with asthma or COPD were randomized to receive two forms of salbutamol metered-dose-inhalers (MDIs), i.e. CFC-driven MDI, non-CFC (HFA) MDI and one salbutamol dry powder inhaler (DPI), in a multi-center, comparative, cross-over and randomized study, performed to facilitate the formulation of a strategic plan to phase out CFC MDIs. After having received all three forms of test products, the patients completed an evaluation questionnaire indicating their preferences, likelihood of treatment compliance on each product and the easiest one to use. Statistical analysis showed that the CFC MDI was significantly less irritating (p < 0.014) but lower in its overall appeal (p < 0.0001). The "most preferred form to be prescribed" was DPI at 47.5% followed by non-CFC at 32.5% and CFC MDI at 20.1%. Concerning the ease of use among the three forms of test products, 59.9% of the patients indicated "no difference". Adverse events were mild and occurred in only 8.2%. In conclusion, patients' preference and sensory perception among the three forms of inhalers were comparable except that the CFC MDI was significantly less irritating but lower in its overall appeal. DPI was the most preferred and easiest form to use but also the most expensive. Taking public health into consideration, a non-CFC MDI with a similar market price to the CFC MDI would be the obvious choice in a strategic plan to phase out CFC MDIs with the least difficulty to the consumers.

Pharmacologic and anti-IgE treatment of allergic rhinitis ARIA update (in collaboration with GA2LEN)

The pharmacologic treatment of allergic rhinitis proposed by ARIA is an evidence-based and step-wise approach based on the classification of the symptoms. The ARIA workshop, held in December 1999, published a report in 2001 and new information has subsequently been published. The initial ARIA document lacked some important information on several issues. This document updates the ARIA sections on the pharmacologic and anti-IgE treatments of allergic rhinitis. Literature published between January 2000 and December 2004 has been included. Only a few studies assessing nasal and non-nasal symptoms are presented as these will be discussed in a separate document.

Periplaneta americana arginine kinase as a major cockroach allergen among Thai patients with major cockroach allergies

Periplaneta americana is the predominant cockroach (CR) species and a major source of indoor allergens in Thailand. Nevertheless, data on the nature and molecular characteristics of its allergenic components are rare. We conducted this study to identify and characterize the P. americana allergenic protein. A random heptapeptide phage display library and monoclonal antibody (MAb) specific to a the P. americana component previously shown to be an allergenic molecule were used to identify the MAb-bound mimotope and its phylogenic distribution. Two-dimensional gel electrophoresis, liquid chromatography, mass spectrometry, peptide mass fingerprinting, and BLAST search were used to identify the P. americana protein containing the MAb-specific epitope. We studied the allergenicity of the native protein using sera of CR-allergic Thai patients in immunoassays. The mimotope peptide that bound to the MAb specific to P. americana was LTPCRNK. The peptide has an 83-100% identity with proteins of Anopheles gambiae, notch homolog scalloped wings of Lucilia cuprina, delta protein of Apis mellifera; neu5Ac synthase and tyrosine phosphatase of Drosophila melanogaster, and a putative protein of Drosophila pseudoobscura. This finding implies that the mimotope-containing molecule of P. americana is a pan-insect protein. The MAb-bound protein of P. americana was shown to be arginine kinase that reacted to IgE in the sera of all of the CR-allergic Thai patients by immunoblotting, implying its high allergenicity. In conclusion, our results revealed that P. americana arginine kinase is a pan-insect protein and a major CR allergen for CR-allergic Thai patients.

Availability and consumption status of CFC and non-CFC inhalers for asthma and chronic obstructive pulmonary diseases in Thailand

In response to the Montreal Protocol and the calls for global early-bird CFC phase-out before 2010, the demand and supply status of both CFC and non-CFC inhalers for prevention and treatment of asthma and COPD in Thailand were evaluated to determine how soon the country would be able to discontinue CFC MDIs with least impacts to both consumers and importers. Availability and supply of the inhalers were collected from registration and importation database of the Thai FDA. Demand and product cost were obtained from the local importers and from IMS, Thailand. Available inhaled products comprise of 39% CFC MDIs, 28% DPIs, 20% solutions for nebulizers and 13% HFA MDls, respectively. All 31 brands of portable hand-held inhalers, comprising 16 CFC MDIs, 6 HFA MDIs and 9 DPIs, are imported, only solutions for nebulization are locally manufactured. Salbutamol is mostly prescribed MDI, its consumption is over 50% of all. The transition to non-CFC alternatives (HFA MDIs and DPIs) has become evidence since 2000. After being informed about the demand and supply of the inhalers, in 2005, Thai FDA has announced its CFC phase-out policy and encouraged importation of HFA alternatives by facilitating the registration and approval process. When the most prescribing CFC MDls, salbutamol, is completely replaced with non-CFC form in 2006, Thailand would be able to reduce considerable amount of CFCs into our atmosphere.

Quality of life assessment in Thai patients with allergic rhinoconjunctivitis using the SF-36 questionnaire (Thai version)

The health related quality of life (QOL) of patients with allergic rhinitis and/or conjunctivitis (ARc) as measured by the SF-36 questionnaire, has been shown to be impaired in a similar way to that of asthmatic patients in France and several other countries. We used the SF-36 questionnaire (Thai version) to evaluate the QOL of Thai ARc patients compared to healthy subjects. The SF-36 questionnaire (Thai version) consists of 36 items covering 8 dimensions and one health transition report question. Higher scores indicated better QOL. The internal consistency reliability of the questionnaire was analysed using Cronbach's alpha-coefficient. A total of 705 healthy persons and 900 ARc patients were included in this study. The mean difference of the scores between healthy and ARc groups in each dimension showed higher scores in the healthy group. This difference was statistically significant (p < 0.05 and p < 0.001) for all dimensions, except for the Social Functioning dimension. The internal reliability of the SF-36 questionnaire was confirmed by Cronbach's alpha-coefficient which was above 0.7 for seven of the dimensions; the exception was the Social Functioning dimension. Men were shown to have higher scores than women in several dimensions. In conclusion, this study has confirmed that the SF-36 questionnaire is sensitive enough to discriminate ARc patients from healthy persons with high reliability. QOL of ARc patients was significantly more impaired than healthy persons and hypertensive patients in several dimensions. These findings were similar to reports from other countries using the same instruments. Therefore the SF-36 questionnaire (Thai version) can be a useful tool in evaluating the impact of ARc on a patient's QOL and the improvement in QOL after therapeutic intervention in Thai patients.

The levels of cockroach allergen in relation to cockroach species and allergic diseases in Thai patients

Recently, cockroaches have been established as the second most Important allergen, producing allergic diseases, especially in low socioeconomic populations. In Thailand, about 44-61% of atopic patients were positive to cockroach extract by a skin-prick test. This study examined cockroach allergen levels in relation to cockroach species and allergic diseases in the houses of cockroach-sensitive patients. Sixty households of allergic patients in the Bangkok metropolitan area were surveyed using open- and closed-ended questionnaires. Cockroaches were collected using commercial cockroach traps, while dust samples were obtained from the bedrooms, kitchens and living rooms of the houses using a vacuum cleaner. The cockroaches were counted and their species Identified. The levels of cockroach allergens were determined by specific monoclonal antibodies using a monoclonal antibody-polyclonal antibody based sandwich ELISA kit. Six cockroach species were Identified: Periplaneta americana (American cockroach, 72.15%), Supella longlpalpa (2.75%, found in only one house), Periplaneta brunnea (0.78%), Periplaneta australaslae (0.78%), Neostylopyga rhombifolla (0.78%), Blattella germanica (German cockroach, 0.39%) and nymphs (22.35%). Allergens of the predominant species, P. americana, were detectable in all homes studied, with the highest levels in the kitchen areas. The range of allergen levels in house dust varied from 0.40-162.00 microg per g of dust. The median and mean allergen levels in kitchen dust were 59.16 microg and 62.80 microg per g of dust, respectively, while the median allergen level in bedroom dust was only 15.90 microg per g of dust. The German cockroach allergen (Bla g 2) was undetectable in any of the houses.

IN CONCLUSION

P. americana was the most common cockroach and may be the species causing allergic diseases, especially asthma, in Thailand, which differs from the USA and Europe

Development of a health-related quality of life questionnaire for Thai patients with rhinoconjunctivitis

The objective of this study was to develop a disease-specific questionnaire for patients with rhinoconjunctivitis. All patients were recruited at the Out-Patient Clinic at Siriraj Hospital. Related topics were gathered from several sources, and a list of 63 items was produced. In phase I, the first version of the questionnaire was completed by 363 patients. Forty-eight items were identified by clinical impact analysis during the item removal process, two more questions were then added, giving a total of 50. Two hundred and forty-three patients completed the second version questionnaire in phase II. The average time taken to complete the questionnaire was 6.38 minutes. The item removal process in phase II was achieved by a multi-step process. There were 36 items in the third version questionnaire which consisted of six dimensions and two independent items as follows: symptoms (17 items), physical functioning (3 items), role limitations (3 items), sleep (3 items), social functioning (3 items), emotions (5 items), general health (1 item), and absenteeism (1 item). The scores of each item ranged from 1 to 5; a lower score indicating a better quality of life. Data from the selected 36 items was extracted to test the validity and reliability of the final version. The floor and ceiling effects of the scores for each dimension were low. Multitrait multi-item analysis was conducted to examine construct validity. The scaling success of convergent and divergent validity was 100% and 94%, respectively. Internal consistency determined by Cronbach's alpha coefficient, was satisfactory (0.79-0.87). The study indicates that the questionnaire is suitable for use in clinical settings. While the test results are encouraging, further work needs to be done on the test-retest reliability and on responsiveness.

An open label, randomized comparative study of levofloxacin and amoxicillin/clavulanic acid in the treatment of purulent sinusitis in adult Thai patients

The objective of the study was to compare the clinical efficacy and bacteriological response of levofloxacin and amoxicillin/clavulanic acid (co-amoxiclav) in the treatment of purulent maxillary sinusitis. Sixty patients randomly received either levofloxacin 300 mg orally once daily (LEV group) or co-amoxiclav 625 mg three times a day (COA group) for 14 days. Thirty four patients were in the LEV group and 26 patients were in the COA group. The mean total symptom score was significantly decreased after treatment and was comparable between both groups. Radiological improvement was 61.8% in the LEV group (41.2% resolution, 20.6% improvement) and 61.5% in the COA group (26.9% resolution, 34.6% improvement). Pretreatment maxillary antral aspiration cultures were positive in 28 patients (82.4%) in the LEV group and 20 patients (76.9%) in the COA group. Bacteriological eradication was 78.5% in the LEV group and 70.0% in the COA group, which was not significantly different. In the LEV group, the eradication rate for major pathogens of acute sinusitis was 100% for H. influenzae (both betalactamase +ve and -ve), 100% for S. pneumoniae and S. aureus, 100% for Neisseria species, and 66.7% for P. aeruginosa. The eradication rate in the COA group was 75% for H. influenzae (both betalactamase +ve and -ve), 100% for S. pnumoniae and S. aureus, 50% for Neisseria species, and 0% for P. aeruginosa. There were no significant changes in vital sign measurements or hemato-biochemical parameters at the end of treatment as compared to baseline values, in both groups. Adverse events were found in 8.8% of patient in the LEV group and in 7.7% of patients in the COA group. Adverse events included nausea, abdominal pain, and diarrhea. All the adverse events in both groups were mild and resolved spontaneously. This study demonstrated that levofloxacin 300 mg orally once daily was as effective and safe as amoxicillin/clavulanic acid 625 mg three times a day in the treatment of maxillary sinusitis, either acute or acute exacerbation. Both drugs showed bacteriological efficacy that was not significantly different. The once daily dosage regimen is more applicable, convenience and has better compliance.

An open-label, prospective study of an oral polyvalent bacterial lysate (Luivac) in the treatment of recurrent respiratory tract infections in Thai patients

An open-label, non-comparative study was performed in the Department of Otolaryngology, Siriraj Hospital, Bangkok, Thailand, to assess the safety, tolerability, acceptability and efficacy of an oral polyvalent bacterial lysate (Luivac) in the treatment of recurrent respiratory tract infections (RTIs) in Thai patients. Thirty-three patients were included in this study, 18 males and 15 females, with a mean age of 34.0 +/- 14.7 years. The mean number of RTIs during the 12-month period preceding the study was 9.5 per patient. During the study each patient received one tablet of Luivac daily for 28 days followed by a treatment-free period of 28 days. This was followed with another 28 days on Luivac, after which there was a 28-day treatment-free follow-up period. This study lasted 4 months with five scheduled patient visits (V1-V5). Laboratory studies were done at baseline (V1) and after treatment (V4), which included complete blood count and serum immunoglobulins (IgA, IgE, IgG and IgM). The incidence of all adverse events was 15.2% and no case was related to the studied drug. There were no clinical relevant changes in laboratory parameters after treatment. The reduction rate of RTIs per month at the end of the study period was 63.5% when compared to the average RTIs rate per month during the 12 months preceding the study. A comparison of the first study period (V1-V3) and the second study period (V3-V5) showed a reduction in duration of RTIs (23.1%), in the clinical infection score (17.5%), in the number of antibiotics used (2.1%), in the number of symptomatic treatments (3.5%), and in the number of days absent from school or work (50.0%). Overall tolerability and acceptability were assessed as very good and good in 96.8% of the patients. This study suggests that oral polyvalent bacterial lysate (Luivac) was safe and also showed a tendency to be effective in preventing RTIs in Thai patients with or without risk factors for recurrent RTIs. Other clinical advantages were reduction in the severity and duration of infection as well as in reduction of the cost of treatment and the number of days absent from school or work.

Recombinant American cockroach component, Per a 1, reactive to IgE of allergic Thai patients

Twelve similar recombinant Per a 1 clones were produced from an American cockroach (CR) cDNA library. The nucleotide sequence of a representative cline, i.e. clone A6, contained 579 base pairs (bp) and a 372 bp open reading frame (2-373) encoding 124 amino acids. A stop codon was found at position 374-376 followed by a 3' end untranslated region with an AATAAA polyadenylation signal and a poly (A) tail. The estimated molecular mass of the 24 amino acid residue protein was 13.8 kDa, with a predicted isoelectric point value of 4.74. Cysteine or N-linked glycosylation was not found. The deduced amino acid sequence of the A6 revealed 84.68-95.97% identity to other previously reported Per a 1 clones and 65.87-69.60% homology to the previously reported Bla g 1 clones. However, while previously reported Per a 1 clones showed homology to ANG12, a precursor protein in the midgut of the female Anopheles gambiae secreted after the blood meal, the A6 DNA sequence was found to have homology (37.1%) to DNA of G2, a putative protein in the midgut of Aedes aegypti (AY 050565). The deduced amino acid sequence of A6 contained a mitochondrial energy transfer protein signature, phosphorylation sites for the cAMP-and cGMP-dependent protein kinase C and casein kinase II. Hydrophobic and hydrophilic characteristics of the A6 deduced peptide indicated that it was a transmembrane protein. This is the first report that Per a 1 is a transmembrane protein. The deduced amino acid sequence of the A6, which contained the sequence LIRSLFGLP, differed in one amino acid from two previously reported epitopes, i.e. LIRALFGL and IRSWFGLP, of Per a 1.0104 which bound 80% and 100%, respectively, to IgE of the allergic patients tested. The A6 DNA sequence was deposited in the GenBank (Accession number AY 259514) and has been designated Per a 1.0105. The A6 expressed protein bound to monoclonal antibodies (MAb 3C2) specific to American cockroach and also bound to IgE of all (100%) of the 20 allergic Thai patients.